Available to Work
Are there any days or hours you would be unable or unwilling to work? *
Have you lived outside of the state of Pennsylvania within the last two years? *
Have you ever filed an application or been employed with another provider service angency? *
Do you have the legal right to be employed in the United States? *

Work History

List the names of all employers, giving the most recent position first. Please give the month and year for each position listed. In addition, be sure to list all health or human services providers for which you have worked.

Employer 1

Employer 2

Employer 3

Have you signed a restrictive covenant/non-compete agreement or confidentiality statement at a prior job? *
Have you ever been disciplined or discharged by an employer for client abuse or neglect? *
Have you ever been convicted, (or plead guilty) of any crime (felony, misdemeanor, or summary offense)? Please include any incidence of driving while intoxicated. *

(Information regarding convictions will not necessarily disqualify you for employment, but will be reviewed in light of the duties and responsibilities of the position being sought.)

Currently valid? *

A valid license, good driving history, and proof of insurance are required for many positions.


High School

High School Years Completed
High School - Graduated?

Undergraduate College

Undergraduate College Years Completed
Undergraduate College - Graduated?

Graduate/Professional College

Graduate/Professional College Years Completed
Graduate/Professional College - Graduated?

Professional License and/or Certifications

Has your professional license ever been suspended or revoked? *

Emergency Contact


Are you currently employed? *
If yes, may we contact your present employer? *

Reference #1

Reference #2

Direct Care Worker Agreement of Hours to Work

If offered a position as a Direct Care Professional, I agree to be available for scheduling the following days and times. I understand that I must work a minimum number of hours (agreed upon by management) to maintain employment status at Lifeway Services LLC, as a Direct Care Professional.

I understand that by committing to and signing this agreement I will be given a schedule that is suitable to what I have indicated below as a new employee with Lifeway Services LLC.

I also understand that if I refuse to accept a schedule that I have stated I am available for, I will risk not being assigned any hours to work for an unspecified period of time as it may also lead to being separated as a Lifeway Services LLC employee if there are no available hours.

I understand that I cannot request a change of my availability during the 90 day probationary period.

After the 90 day probation period, as a Direct Care Professional, if my schedule availability were to change (i.e., for reasons such as school, scheduling, another job, etc.) I understand that a formal request must be made and approved by management. However, I would continue to remain committed to work the schedule that I would be given initially until such changes would be approved.


A face-to-face interview will be conducted on all potential employees prior to being hired. Additional interviews may be required before a position may be offered to an applicant.

Please bring a copy of the following to the interview:

  • Social Security Card
  • Driver's License/Photo ID
  • Auto Insruance card/level of coverage
  • Any training certificates/competency trainings
  • Prior work-related experiences
  • Intellectual Disability work experience